Bipolar Disorder
Bipolar disorder, also known as manic depression, is a chronically recurring condition involving moods that swing between the highs of mania and the lows of depression. Depression is by far the most pervasive feature of the illness. The manic phase usually involves a mix of irritability, anger, and depression, with or without euphoria. When euphoria is present, it may manifest as unusual energy and overconfidence, playing out in bouts of overspending or promiscuity, among other behaviors.
The disorder most often starts in young adulthood, but can also occur in children and adolescents. Misdiagnosis is common; the condition is often confused with attention-deficit/hyperactivity disorder, schizophrenia, or borderline personality disorder. Biological factors probably create vulnerability to the disorder within certain individuals, and experiences such as sleep deprivation can kick off manic episodes.
There are two primary types of bipolar disorder: Bipolar I and Bipolar II. A major depressive episode may or may not accompany bipolar I, but does accompany bipolar II. People with bipolar I have had at least one manic episode, which may be very severe and require hospital care. People with bipolar II normally have a major depressive episode that lasts at least two weeks along with hypomania, a mania that is mild to moderate and does not normally require hospital care.
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The defining feature of bipolar disorder is mania. It can be the triggering episode of the disorder, followed by a depressive episode, or it can first manifest after years of depressive episodes. The switch between mania and depression can be abrupt, and moods can oscillate rapidly. But while an episode of mania is what distinguishes bipolar disorder from depression, a person may spend far more time in a depressed state than in a manic or hypomanic one.
Hypomania can be deceptive; it is often experienced as a surge in energy that can feel good and even enhance productivity and creativity. As a result, a person experiencing it may deny that anything is wrong. There is great variability in manic symptoms, but features may include increased energy, activity, and restlessness; euphoric mood and extreme optimism; extreme irritability; racing thoughts, unusually fast speech, or thoughts that jump from one idea to another; distractibility and lack of concentration; decreased need for sleep; an unrealistic belief in one's abilities and ideas; poor judgment; reckless behavior including spending sprees and dangerous driving, or risky and increased sexual drive; provocative, intrusive, or aggressive behavior; and denial that anything is wrong.
The duration of elevated moods and the frequency with which they alternate with depressive moods can vary enormously from person to person. Frequent fluctuation, known as rapid cycling, is not uncommon and is defined as at least four episodes per year.
Just as there is considerable variability in manic symptoms, there is great variability in the degree and duration of depressive symptoms in bipolar disorder. Features generally include lasting sad, anxious, or empty mood; feelings of hopelessness or pessimism; feelings of guilt, worthlessness, or helplessness; a loss of interest or pleasure in activities once enjoyed, including sex; decreased energy and feelings of fatigue or of being "slowed down"; difficulty concentrating, remembering, or making decisions; restlessness or irritability; oversleeping or an inability to sleep or stay asleep; change in appetite and/or unintended weight loss or gain; chronic pain or other persistent physical symptoms not accounted for by illness or injury; and thoughts of death or suicide, or suicide attempts.
The symptoms of mania and depression often occur together in "mixed" episodes. Symptoms of a mixed state can include agitation, trouble sleeping, significant change in appetite, psychosis, and suicidal thinking. At these times, a person can feel sad yet highly energized.
About 2.8 percent of American adults have had bipolar disorder in the past year, according to the National Institute of Mental Health, and 4.4 percent experience bipolar disorder at some time in their lives. These rates are similar among men and women. Worldwide, the disorder affects about 45 million people, according to the World Health Organization.
Most people with bipolar disorder develop the condition in their late teens or early twenties, although symptoms can appear in children as young as six years old. The average age of a first episode of mania, hypomania, or depression is 18 years old for bipolar I and mid-20s for bipolar II, according to the DSM-5.
Symptoms in children and teens are similar to those in adults and include the condition's hallmark mood swings. Children with bipolar disorder undergo extreme changes in mood and behavior, feeling unusually happy and energetic during manic episodes and becoming very sad and less active during depressive episodes. Manic episodes may involve increased energy, distractibility, grandiosity, and inability to sleep while depressive episodes may involve self-harm or suicidal thoughts and gestures, which should be taken seriously.
One key factor: bipolar is episodic while other disorders are pervasive. For example, bipolar symptoms come and go in mood swings, while disorders like ADHD tend to be more consistent if left untreated.
People often struggle with unidentified and untreated bipolar disorder for years. In fact, about two-thirds of people with bipolar disorder are misdiagnosed before bipolar is discovered.
Most of these individuals are misdiagnosed with depression. When thinking about the difference between the two, patients and clinicians can consider family history due to the genetic roots of the disorder, and personal history of unexplained excitability and euphoria or rage, self-harm, and suicidality. Antidepressants can trigger mania in some cases; it’s critical to monitor if a patient feels more agitated, irritable, aggressive, or hyperactive after beginning medication.
In the case of schizophrenia, manic episodes can include or resemble psychosis, while depressive episodes resemble the negative symptoms of schizophrenia. (Such patients may receive a diagnosis of schizoaffective disorder, bipolar type.)
Both genetic and environmental factors can create vulnerability to bipolar disorder. As a result, the causes vary from person to person. While the disorder can run in families, no one has definitively identified specific genes that create a risk for developing the condition. There is some evidence that advanced paternal age at conception can increase the possibility of new genetic mutations that underlie vulnerability. Imaging studies have suggested that there may be differences in the structure and function of certain brain areas, but no differences have been consistently found.
Life events including various types of childhood trauma are thought to play a role in spurring bipolar disorder in those who are already vulnerable to developing the condition. Researchers do know that once bipolar disorder occurs, life events can precipitate its recurrence. Incidents of interpersonal difficulty and abuse are most commonly associated with triggering the disorder.
“Family history is the strongest and most consistent factor for bipolar disorder,” states the DSM-5. The risk is 10 times greater for those who have a relative with bipolar I or bipolar II. Genes that are passed down in a family with bipolar appear to influence how the brain handles mood regulation.
When attempting to explore a bipolar diagnosis, it’s vital to understand the family history of mental health to know whether an individual may be predisposed. For example, it’s worth considering if anyone in the family, particularly one’s closest relatives, has experienced severe mood swings, intensely erratic behavior, or high irritability followed by deep sadness.
Some people with traumatic brain injuries (TBI)—due to a car accident or a sports injury, for example—experience heightened levels of anxiety, depression, and mood swings. Individuals with a TBI are four times more likely to develop a mental illness, according to a Danish study of more than 100,000 people with head injuries. People with a TBI are 28 percent more likely to develop bipolar disorder, 59 percent more likely to develop depression, and 65 percent more likely to develop schizophrenia.
Bipolar disorder has biological roots, but life experiences may trigger or exacerbate it. Many patients cite a specific psychosocial trigger for their first episode of bipolar disorder, such as a breakup, family trauma, substance use, or period of stress. Being aware of these factors is important for both identifying and treating bipolar.
Because bipolar disorder is a recurrent illness, long-term treatment is necessary. Mood stabilizer drugs are typically prescribed to prevent mood swings. Lithium is perhaps the best-known mood stabilizer, but newer drugs such as lamotrigine have been shown to cause fewer side effects while frequently obviating the need for antidepressant medication. Used alone, antidepressants can precipitate mania and may accelerate mood cycling. Getting the full range of symptoms under control may require other drugs as well, either short-term or long-term.
Nutritional approaches have also been found to have therapeutic value. Studies show that omega-3 fatty acids may help lower the number or dosage of medications needed. Omega-3 fatty acids play a role in the functioning of all brain cells and are incorporated into the structure of brain cell membranes.
Work and relationship problems can be both a cause and effect of bipolar episodes, making psychotherapeutic treatment important. Studies show that such treatment reduces the number of mood episodes patients experience. Psychotherapy is also valuable in teaching self-management skills, which help keep one's everyday ups and downs from triggering full-blown episodes.
In addition to medication management, therapy is an important component of treating bipolar disorder. Evidence-based therapies include Cognitive Behavioral Therapy—which helps patients reframe harmful or irrational thoughts to change mood and behavior—as well as Interpersonal Therapy, Family-Focused Therapy, and psychoeducational approaches. Family-Focused therapy may be particularly helpful for children and teens with bipolar disorder.
Therapy helps treat bipolar disorder through many different pathways. Therapy offers psychoeducation to improve medication compliance, skills to cope with the challenges of living with the condition, lifestyle remedies, connection to loved ones for greater support, and immediate help for crises that might trigger a manic or depressive episode. Patients come to treatment with different goals, so a therapist should encourage patients to share those goals and work collaboratively to find the right approach.
People with bipolar disorder typically need medication, but choosing the right drug or drug combination often requires some trial and error. To determine the right treatment, the psychiatrist may start with a low dose and gradually increase it based on the patient’s response and tolerance. They will seek feedback from the patient, and prescribe one medication at a time to find the best fit.
Patients may experience difficult side effects, such as fatigue, weight gain, and nausea. Lifestyle changes can help manage those symptoms—patients can exercise, maintain a healthy diet, keep a regular sleep schedule, and seek social support.
Sharing concerns about medication in therapy is important so that patients and clinicians can determine the best path forward. If one medication has not worked well, there may be other options to explore. If there are concerns around the stigma of psychiatric medication or fears of maintaining one’s sense of self, a therapist can provide clarity and support.
Bipolar disorder can wreak havoc on a person's goals and relationships. But in conjunction with proper medical care, sufferers can learn coping skills and strategies to keep their lives on track. Bipolar disorder, like many mental illnesses, is sometimes a controversial diagnosis. While most sufferers consider the disorder to be a hardship, some appreciate its role in their lives, and others even link it to greater creative output.
While the depression of bipolar disorder is hard to treat, mood swings and recurrences can often be delayed or prevented with a mood stabilizer, on its own or combined with other drugs. Psychotherapy is an important adjunct to pharmacotherapy, especially for dealing with work and relationship problems that typically accompany the disorder. Clinicians are well aware that there is no one-size-fits-all cure: An individual with a first-time manic episode will not be the same as an individual who has lived with bipolar for a decade.
The fear of losing one’s creativity, productivity, and sense of identity can prevent people from seeking help. But neglecting treatment to preserve manic energy often leads to a crash that can threaten every aspect of the person’s well-being.
A therapist can allay these concerns and redefine creativity. The intense rise of manic energy is sometimes confused for creativity rather than disorganized and reckless output; mania can delude the person into believing their skills are greater than they truly are. A therapist can help a patient with bipolar to steadily harness their creative abilities following mood stabilization and develop an organized strategy and timeline to achieve their goals.
Many individuals with bipolar disorder experience hyper-religiosity during mania. Fifteen to 22 percent of those with bipolar mania in the U.S. experience religious delusions, such as thinking that demons are watching them or that they are Christ reborn.
The complex phenomenon of spirituality involves networks of multiple brain regions. Parts of the parietal lobe are associated with feelings of spiritual transcendence, parts of the temporal and frontal cortices are involved in the storage and retrieval of religious beliefs in memory, and still other parts of the frontal lobe and limbic structures are responsible for rational and emotional aspects of religious beliefs. Dopamine levels in those with bipolar disorder may play a role in elevating religious and spiritual experiences.
The experience of bipolar disorder can differ between people. While not discounting the tremendous toll the disorder takes on many lives, some people with bipolar disorder believe the condition confers certain advantages, such as creativity, motivation, and leadership. Famous figures are often cited to illustrate the connection between genius and mental illness, such as Vincent van Gogh, Winston Churchill, and more recently, Kanye West.
One common misconception about bipolar disorder is that mania is always “good” because it’s better than being depressed. But people in a manic episode often do ignorant or foolish things, make mistakes, and hurt other people. Another misunderstanding is that actions during manic periods are fully voluntary, but the person doesn’t have complete control over their faculties.
Another misunderstanding is that treatment ends when a person is stable. Bipolar disorder is chronic, so maintaining stability, incorporating lifestyle changes, and being aware of triggers is an ongoing process.